(Adapted from a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (writing committed to developing an expert consensus document on complementary and integrative medicine) published Journal of the American College of cardiology volume 46 No 1 2005.)

Although not considered mainstream, complimentary, alternative and integrative medical therapies (CAM) are widespread, and a large percentage of American adults are utilizing the services of one or the other form of CAM for prevention of cardiovascular diseases.

also improve endothelial function, help reduce blood pressure, reduce fibrinogen levels and prevent ventricular arrhythmias. Multiple studies have been published to date with mixed results. However, the most persuasive evidence of the benefit comes from the GISSI (Italian) Prevenzione study which demonstrated a sharp 20% reduction in mortality and 45% reduction in the incidence of sudden death by supplementing Omega 3 fatty acids by 1 g a day.

RECOMMENDATION-YES CAN BE USED

There does not exist significant evidence in the literature demonstrating the harmful effects of Omega 3 fatty acids. Multiple studies point towards beneficial effects. Supplementing Omega 3 fatty acids along with a complete lipid-lowering regimen may have cardiovascular risk reduction benefit.

2.PHYTOSTEROLS-

Phytosterols (Plant stanols/sterols) also have a modest cholesterol-lowering effect. Consumption of 2 g of phytosterols per day can reduce bad cholesterol by 5-15%. Phytosterols are naturally occurring compounds found in plants. They are similar in structure to human cholesterol and reduce cholesterol levels by competing with the absorption of cholesterol in the intestine. Good natural sources are vegetables, fruits, nuts, grains,cereals,nuts and soyabean.The effects of phytosterols on cardiovascular morbidity and mortality have not been determined. There is however an FDA approved claim that Plant esters taken as a serving of 0.65 g per serving twice a day with meals or plant stanol esters consumed 1.7 g per serving twice a day may reduce the risk of heart disease.

There are commercially available oil-based products providing 3.4-5.1 g a day of planned sterols which can reduce LDL by 10-20%. No trial has directly demonstrated cardiovascular risk reduction by consuming stanol/sterol esters.

For diet, which is rich in fruits and vegetables, nuts and oils as recommended, no additional supplementation is required for phytosterols.

There has been no harm demonstrated using garlic. Available scientific data does not recommend using it as a supplement to prevent cardiovascular risk.

4.SOY-

Soybean-based foods have cholesterol-lowering, estrogenic and antioxidant properties. Consumption of soy protein can reduce LDL by approximately 10%, total cholesterol by approximately 10% and triglycerides by 10% and increase HDL by 2.5%.

However, the evidence is inconclusive that soy proteins are useful for reducing cardiovascular risk.

RECOMMENDATION- YES

No studies are demonstrating the harmful effects of soy proteins. Consuming Soy-based natural products can be an additional supplement to a comprehensive risk prevention strategy including appropriate therapies instituted for lipid management outlined in the program, including statins where indicated.

5.SOLUBLE FIBERS-

There are four types of soluble or viscous fibers such as oat bran, Psyllium, Guar, and pectin which have small but significant cholesterol and LDL cholesterol reduction benefit. However insoluble fibers such as cellulose and wheat fiber have no natural cholesterol reducing effect. There is also epidemiological evidence that demonstrates a reduced risk of heart attack and death from coronary artery disease in both man and woman who consumed a higher amount of dietary fiber. Dietary fibers also reduce high blood pressure, obesity, insulin resistance, and clotting factors. Increasing the dietary fibers by adding 5-10 g of soluble fiber every day, is a safe and practical approach for cholesterol reduction.

RECOMMENDATION-YES

Highly recommended as a complementary therapy with the lipid-lowering regimen. Soluble fibers should not be considered a stand-alone treatment for the prevention of cardiovascular risk.

6.NUTS-

A consistent benefit of nut consumption about cardiac risk prevention has been demonstrated both in anthropomorphic and prospective studies. The benefit observed is more than the resulting improvement in serum lipid levels. Nuts are high in arginine, magnesium, folate, planned sterols, and soluble fiber and also a rich source of vitamin E.

RECOMMENDATION- YES

Five ounces of nuts consumed per week especially, the tree nuts such as almonds, walnuts, and hazelnuts with appropriate adjustments made in overall caloric intake are a recommended dietary supplement for cardiovascular risk reduction. Nut consumption complements but does not substitute a complete lipid-lowering regimen.

7.TEA-

Evidence from Epidemiologic studies supports the protective benefit of drinking tea for cardiac risk reduction. There is however no prospectively randomized study demonstrating cardiovascular risk reduction with the drinking of tea. The benefit may be related to flavonoids.

RECOMMENDATION-YES

Drinking tea two cups a day (14 cups per week) may have a beneficial effect on cardiovascular mortality. However, patients with cardiac arrhythmias such as atrial fibrillation should be aware of the potential of caffeine, contained in the tea, exacerbating cardiac arrhythmias.

8.ALCOHOL-

The beneficial effect of moderate alcohol consumption defined as alcohol intake of 1-3 drinks daily has been demonstrated in multiple epidemiologic and observational studies. Moderate alcohol consumption reduces the incidence of heart attack, angina pectoris, coronary related deaths, ischemic stroke, peripheral vascular disease, death following a sudden heart attack. The Incidence of congestive heart failure is also lower in subjects who consume a moderate amount of alcohol daily. The benefit comes from the alcohol itself. There is no data whether a specific type of alcohol such as red or white wine beer or whiskey provides greater or lesser benefit.

RECOMMENDATION- YES (GUARDED).

If you are already a moderate drinker, you should continue to drink to derive benefits outlined above. However, since there are numerous health hazards associated with irresponsible consumption of the alcohol, recommendations for non-drinkers cannot be made without a comprehensive discussion between the patient and his physician about the pros and cons of benefit and harm.

9.VITAMINS AND MINERAL SUPPLEMENTS-

VITAMIN E-

Vitamin E has antioxidant properties. Antioxidants can improve endothelial function, reduce ischemia, prevent progression of atherosclerosis, reduce platelet adhesion aggregation and reduce the synthesis of leukotrienes. Vitamin E has been extensively studied in various primary prevention and secondary prevention trials. Review of several prospective studies and meta-analysis suggest no clear-cut benefit from vitamin E supplementation for the prevention of coronary artery disease.

RECOMMENDATION-NO

VITAMIN C-

There have been observational and prospective studies showing a trend towards a reduction in coronary heart disease risk and stroke in subjects on high dose supplemental vitamin C- 360 mg to 700 mg a day. However, there is no randomized clinical trial explicitly examining the effects of vitamin supplementation on cardiovascular endpoints. Current evidence does not support supplementing vitamin C in preventing heart disease.

RECOMMENDATION-NO

BETA-CAROTENE-

Several trials with beta-carotene supplementation have demonstrated no significant benefit for the prevention of coronary artery disease. Some trials demonstrated an adverse clinical outcome as well as a slightly increased incidence of lung cancer and an increased prevalence of angina with beta-carotene supplementation. Therefore, there does not exist any evidence of beta-carotene for prevention of coronary artery disease.

RECOMMENDATION- NO.

COMBINED VITAMIN TRIALS OF VITAMIN C, VITAMIN E AND BETA CAROTENE.

The largest randomized trial of 20,000 subjects the heart protection study demonstrated no benefit with vitamin D supplementation of 600 mg a day vitamin C supplementation of 250 mg day and beta-carotene supplementation of 20 mg a day over placebo.

The consensus at this point does not support any cardiovascular benefit related to the combined use of vitamin E and C and beta-carotene.

RECOMMENDATION- NO.

VITAMIN B6, B12, AND FOLIC ACID-

Vitamin B6 B12 and folic acid help reduce homocysteine levels. High homocysteine levels are associated with a higher incidence of coronary artery disease and stroke. However, no tried has demonstrated the clinical benefit of reducing homocysteine for prevention of coronary artery disease. Several trials have demonstrated benefit in the form of stroke reduction with lowering homocysteine levels with B6, B12, and folic acid.

MAGNESIUM LEVELS-

There is evidence that magnesium depletion or low magnesium levels may be associated with a high risk of coronary artery disease. There is also epidemiologic evidence suggesting that magnesium may play a role in regulating blood pressure. Some studies have demonstrated a dose-dependent reduction in blood pressure with magnesium supplementation. Small studies have also demonstrated the effect of magnesium on coronary artery disease. Diets rich in magnesium and magnesium supplementation may help prevent coronary artery disease, especially hypertensive subjects.

RECOMMENDATION- MAY BE BENEFICIAL.

Patients with hypertension especially should have to see the magnesium levels checked. Supplemental dietary magnesium in the form of a higher intake of fruits and vegetables is an excellent way to improve magnesium levels and help blood pressure.

COENZYME Q10-

CoQ10 is a free radical scavenger and membrane stabilizer which is involved in oxidative phosphorylation and degeneration of adenosine triphosphate (ATP). Several trials have been performed to evaluate the effect of CoQ10 in patients with congestive heart failure. There is some benefit towards improvement in the quality of life and decrease in hospitalization, but there was no mortality benefit.

Statins inhibit the natural synthesis of CoQ10. In small studies reduced CoQ10 levels are associated with increased risk of myalgias and myopathy. Studies of CoQ10 in decreasing myalgias and myositis are inconclusive. More extensive trials are ongoing and better data may come.

RECOMMENDATION- NEUTRAL.

L-ARGININE-

L-arginine is the precursor of nitric oxide. Nitric oxide is an endothelial-derived relaxation factor which improves coronary artery endothelial function. The potential benefit of L-arginine supplementation at this time is unknown.

This exam is used to assess the electrical impulses of your heart. This evaluation is for irregular heartbeats. Average exam time is 30 minutes. This exam is done only on a treadmill.For the test:

1. You will be asked to disrobe from the waist up and given a gown to wear. The technologist will then hook up an EKG monitor to you for the entire exam, and two resting EKGs will be obtained immediately. 2. You will then be asked to exercise on a treadmill. The average time is 6 to 10 minutes. 3. When peak exercise is reached, you will stop exercising, and we will continue with the evaluation for five minutes. This exam is used to assess the electrical impulses of your heart. This evaluation is for irregular heartbeats. Average exam time is 30 minutes. This exam is done only on a treadmill. This test has three parts: You will be asked to disrobe from the waist up and given a gown to wear. The technologist will then hook up an EKG monitor to you for the entire exam, and two resting EKGs will be obtained immediately. You will then be asked to exercise on a treadmill. The average time is 6 to 10 minutes. When peak exercise is reached, you will stop exercising, and we will continue with the evaluation for five minutes.

Tennis shoes or comfortable walking shoes are a must. We suggest that you bring or wear comfortable clothes for exercising.

Exercise testing results are best done when you have not eaten one hour before the exam.

Medicines can be taken as usual.

This exam is to assess the circulation and muscle motion of the heart. Ultrasound images of the heart will show the movement of the blood in each heart chamber and as it passes the heart valves. The heart chambers and heart walls are measured for size. The motion of the heart is documented for heart function. The exam time is approximately 30 minutes. There is no prep for this exam.For the test:

1.You will be asked to disrobe from the waist up and given a gown to wear. The technologist will then hook up an EKG monitor to you for the entire exam. 2. You will then have an ultrasound of your heart (echocardiogram) to assess the heart muscle, heart valves and heart function. You may eat and take any medicines before the exam.

This exam compares resting and exercise ultrasound images of your heart (circulation) with simultaneous EKG recordings (electrical). This comparison can show if you have coronary artery disease. Average exam time is one hour. This exam will be essentially the same for the treadmill or the supine (lying on your back) bicycle.For the test:

1.You will be asked to disrobe from the waist up and given a gown to wear. The technologist will then hook up an EKG monitor to you for the entire exam, and two resting EKGs will be obtained immediately. 2. You will then have an ultrasound of your heart (echocardiogram) to assess the heart muscle, heart valves and heart function. 3. You will then be asked to exercise on a treadmill or supine bicycle for an average time of 6 to 10 minutes. 4. When your peak exercise is reached, you will stop exercising and again have an ultrasound of your heart. Comparisons are then made of both sets of heart images and the EKG to complete the exam.

Please wear or bring tennis shoes or comfortable walking shoes. If you have specific exercise desires (treadmill vs. supine bike), please let our scheduler know, and you will be accommodated. We suggest that you bring or wear comfortable clothes to exercise in. Dresses or culottes are not appropriate attire. Exercise testing results are best done when you have not eaten one hour before the exam. Medicines can be taken as usual.

The pacemaker system performs two functions: pacing and sensing.

Pacing An electrical stimulus comes from the generator and travels down the lead to stimulate the heart muscle, causing the heart to contract. The pacemaker is set for a certain heart rate–for example, 70 beats/minute (bpm).

Sensing The lead not only delivers an electrical stimulus to the heart muscle, but it also senses or “sees” your heart’s own natural activity and does not pace if your heartbeat is faster than the programmed rate of the pacemaker.

If you need a pacemaker, your doctor will explain the causes of your rhythm disturbance and why it is necessary. You will then be asked to sign a consent form.

Your physician will discuss the particular type of pacemaker best suited to your needs